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Thursday, March 23, 2017

It's Magic ...

... or Just Doin' my Job, Ma'am.

Remember playing -peek-a-boo with a baby? 
Remember how the baby is all excited that you managed to disappear behind your hands, then magically reappear? 
Babies are fascinated by your magical skills. 
They giggle. They laugh. They love you. 

I was reminded of this last week when a prescriber called me to question a dose she prescribed for her pediatric patient. (Let's ignore the fact that she waited until 6 hours after sending the e-script to call, by which time the patient's mom already picked up and administered a dose.)

CP: Thank you for calling CP's pharmacy where you currently have the privilege of speaking to the infamous, self-deprecating CP. How may I help you? 
Following Through on Writing: I was calling to double-check the dosing on a prescription I sent over for Little Tyke earlier. 
CP: I recall. Is that the one for Amoxicillin 250mg/5ml? 
FTW: It is. I usually calculate my own doses but I let the computer calculate it for me and I didn't double-check. It doesn't round and I entered the patient's weight and just went with what it said. It seems a little high now that I think about it. 
CP: I remember this one. Mom already came and got it and we talked to her about it. 
FTW: Really? 
CP: Yes, but do not worry. We calculated the dose several times. We have students on rotation and one of the doses I make them memorise is the max of Amoxicillin. This worked out well because I had them do the calculation. 
FTW: But I didn't put the weight on the prescription. 
CP: I know. We don't need it. In any equation, as long as you have 2 of the 3 numbers, you can solve for the 3rd. We knew the max dose per day and we knew the dose you prescribed. Using these numbers we could find the patient's weight. We put a note on the patient's prescription at pickup. We asked mom to verify that LT weighed at least 70lbs and was being treated for strep. 
FTW: How'd you do that? That's amazing. LT was diagnosed with strep and weighs 73 lbs. Really? You did all that? 
CP: It's what we do here. The dose appeared high so we double-checked it. It was a great exercise for my students and for me. As Bon Jovi sang, "It's my license". 
FTW: "It's my life"? 
CP: You get me! Anyway, I know not all 12 year olds weigh the same. I make my students memorise other max doses as well so they can quickly calculate doses on the most commonly prescribed or recommended products for parents and their children. (Benadryl, Ibuprofen, and Acetaminophen especially.) Besides, if the dose seems off or if mom didn't answer the questions at pickup correctly, we would certainly have called you before it left the pharmacy. 
FTW: I'm so impressed! I never knew you guys did that. Thank you so much for looking out for us and our patients. 
CP: We all have the same goals in mind. You and I share the same patients and we're both busy. We are the last line of defence from a bad day. I know medications. I know doses. I know how to quickly calculate doses in my head. It's what I do. 

#WhyYouLoveYourPharmacist

Tuesday, March 21, 2017

An Insurance Paradox

Herr S: I wish to obtain my prescription.
CP: Certainly. You may pay the cash price or you may present us with insurance.
HS: I have insurance.
CP: Wunderbar! Please present it.
HS: You have it on file.
CP: I do not.
HS: You most certainly do. I come here all the time.
CP: I do not care where you come, only where you purchase prescriptions.
HS: I come here for prescriptions.
CP: We only accept cash or insurance, not come.
HS: There's something wrong with you.
CP: Yes, but you keep coming back...
HS: Anyway my insurance is, has been, and always will be, on file.
CP: Right. Unless it changes.
HS: Nothing has changed.
CP: Are you sure?
HS: Absolutely.
CP: Care to wager on it?
HS: Well maybe the group number changed.
CP: Maybe?
HS: Yes. Maybe. A little.
CP: Is it "yes" or "maybe"? It can't be both. You can't be "a little pregnant" or "maybe dead".
HS: Try this.  <presents card info>
CP: Wow. That worked.
HS: I preferred knowing and not knowing.
CP: Is that like going and not going?
HS: Something like that.
CP: Have a lovely day, Mr. Schrodinger. Come again.

Monday, March 20, 2017

You Know Nothing!

I walked into work the other day to witness a lady holding court with 2 of her friends. She was, how do I put it, "educating" her friends about OTC allergy medications.

Lady: That Cetirizine you're holding? It's like $0.98 at the dollar store down the street. The one they sell is better than this one. I've taken all of these OTC ones and the only ones that work are Xyzal and Cetirizine. (Never mind that Xyzal didn't arrive on store shelves yet.)

Friend Unbeliever: But this is once a day. I think the Cetirizine works better. What's the difference in them?

Lady: This one here, in your hand, has HCL in it. See, mine didn't. It's that extra HCL that makes it more expensive. It's probably why they don't sell it at the dollar store. It doesn't matter because the HCL ones don't work. You need it without the HCL.

Friend The Second: <silently nods in agreement>

Lady: I don't know what that HCL is, but it makes it not work. You're better off going to get the other stuff from the dollar store. This is like 4 times as expensive just for that HCL.

FU: I need it now, so I 'm just going to get this one.

Lady: Okay. But it doesn't work for me.

Now imagine this conversation is taking place among a group of students. A group of medical or nursing students. Because that's what happened.
Reminds me of the day I was with a phriend in a prescriber's office and we met with a CNP who instructed us that antihistamines were for sinus congestion and Sudafed, a decongestant, was for drainage. That was the last time my phriend ever went to that office.

#ALittleEducationIsADangerousThing

Friday, March 17, 2017

Prescriptions Take Time

Like a good wine, prescriptions take time. You cannot rush the process.
CP: Hello kind sir. How may I help you?
GS: I am here to pick up my prescription.
CP: I apologise but I have nothing ready for you.
GS: I am out.
CP: Okay. Was your prescriber to call us? Was it a refill you ordered?
GS: I called my doctor and told them I needed a refill.
CP: That's a good start. When did you ring them?
GS: This morning.
CP: It is currently 10:15am. When did you phone?
GS: About half an hour ago. I need it now.
CP: I see. Thirty minutes is the perfect amount of time to wait for a pizza. Ten to fifteen is perfect for Chinese food. But prescriptions ... need a little time to mature.
GS: What am I going to do?
CP: Did you have your dose today?
GS: Yes. But winter is coming.
CP: Indeed it has come. Spring is actually next on the calendar but there is a day of snow in the forecast.
GS: Can't you just give me some?
CP: Well, seeing as how it's Tuesday AND you contacted the office AND it's only 10:20am AND the office is open AND you've taken your dose for the day ... I cannot. These are all the boxes I must check as "NO" before invoking the emergency powers issued me by the state to write and dispense medication to you. I am sure if you check back later we may have something. Perhaps call before you leave the house?
GS: I guess he just wants me to stop taking my medication for a few days.
CP: Not sure how you can infer that about your prescriber. I am fairly certain you are not his only patient much like you are not mine. Either way, there is a good likelihood he shall send something over before they close. We are open until 10pm so there is still plenty of time. We can call when we receive it.
GS: Fine. I guess I will stop taking them for a few days and see what happens.
CP: Pretty sure that's not what I said. Are you and I even having the same conversation?

Friday, March 10, 2017

Pharmacy Posse

If our professional organizations won't take care of us, then we owe it to ourselves to take matters into our own hands.





My proposal is this: We need to gang up. Not unionize, but gang up. We will form posses. Each band of droogs will be comprised of all the pharmacies in the neighboring town. Our mission will be to harass the harassers. I will go to your store and you will go to mine. Think of us as the next generation of secret shoppers.

We will intimidate the intimidators. Hate the haters. Love the lovers.
We will just mill about the pharmacy waiting, drop off, and pick up areas. If we notice patients giving a hard time to any of the employees, our professional brethren, we will step in as casual customers, and put them in their place.

"Hey, I want them to take their time and not make any mistakes on my prescription. STFU and leave them alone!"
"Do you always treat the people who take care of you with such venom? I bet you yell at the wait staff serving your food. I wonder how many times people have spit in your entree."
"Where do you work? When we get done here, we're phollowing you back to your office to stare and yell at you."
Maybe we could stand uncomfortably close to them. Make eye contact while slowly inhaling the perfume off the back of their necks, then whisper "your hair smells lovely".

Armed only with our wit and CP 5000 Kitana spatulas, we will come to the defence and run interference for our pharmacy phriends in need.

But CP, what about the good ones?
Customer service surveys. Indeed, we all need these to maximize our bonuses. It is the only true measure of a good pharmacy staff. Never mind that stuff about not making mistakes and being the best professional we can be. The only way to know if a pharmacy member is worth her salt is through the totally worthless metrics. This is where we step in.

CP's Army: Excuse me. Did you receive the correct prescription?
Pt: Yes.
CPA: Did the pharmacist review it with you?
Pt: Yes.
CPA: And you are happy with their job performance today?
Pt: Yes.
CPA: She made sure your prescriber didn't kill you. She even called to change the dose on that antibiotic for your baby.
Pt: She did?
CPA: She did. And she didn't even seek credit for it because it's her job.
Pt: I didn't know she did all that.
CPA: You're going to call the 1-800 and give her all positive marks?
Pt: No. I never do those.
CPA: Let me rephrase. (Best Jedi impression): You ARE going to call and give her positive marks.
Pt: I am indeed!
CPA: Good. Feel the Phorce Phlow through you. G'Day!

Of course Option #2 will be to have the patient make the phone call directly from the waiting area.
CPA: Your pharmacist is calling right now to phix your prescriber's phailures in prescribing.
Pt: She is?
CPA: You should call the 1-800 number and thank corporate for employing such an attentive, detail-oriented professional to take care of you. Here, use one of my phones.

Option #3 will go like this:
CPA: You're going to call, right?
Pt: Nope. Piss off.
CPA: Okay. In that case, you got two choices of what you can do. It's not a tough decision as you can see. I can blow you away or you can hand your receipt to me.
Pt: <hands over receipt>
CPA: Thank you. Your positive 1-800 call is on its way. I bet you don't tip your wait staff very well either.

#PharmacyPhuckery


Wednesday, March 1, 2017

If The Real World Worked...

...no one would be responsible for his own actions. Oh, wait...

Remember driving to the video store to rent a DVD? What happened when they were out of the most popular title on Friday night?
Remember standing in line for Black Friday sales and you finally get inside and they are already out of the item you wanted?
Remember heading to the grocery to find they are out of something you need for a recipe?

What did you do?
What recourse did you have?
What actions did you take to receive compensation?
Anything?
No.
In most cases you likely rented another picture, bought an alternative product, and drove to another store or purchased a substitution.

If the real world worked the way people believe pharmacy does, there would have been hell to pay. See, the pharmacy world operates just outside of normal. If there were a rural suburb of normal, this is where Pharmacy World would be located. We'd even have one of those signs that gives the population...and a kid sitting by to change it.

The expectations in this Twin Peaks-esque World are quite skewed. In each of the above scenarios, the outcome would have been the same had they occurred in Pharmacy World, but different than in Normal Town.

CP: I apologise, but we are currently out of this medication.
Can't Comprehend Current Conversation: But why?
CP: We've had quite the run on this today? We never stock it because it costs $1 bajillion? It's brand new and we haven't had call for it yet? Pick one.
CCCC: Don't you know how to stock?
CP: Yes. I order something. It comes in tomorrow. Much like you and your prescriber. She ordered something and now it has to come in tomorrow. As I said, it is quite expensive and no one has prescribed it before. (Or everyone has been writing for it but supplies are limited.)
CCCC: So I have to come back tomorrow?
CP: As I stated, yes.
CCCC: I spent all this time in the drive-thru lane and now I have to do it all over again tomorrow?
CP: Well, you could come inside for a bit of a change of pace and scenery.
CCCC: Who's going to pay for my gas?
CP: Sorry?
CCCC: My gas! All that I wasted while sitting in this interminable line and that I am going to have to use to come back tomorrow!
CP: Hmm. Let me think. That would be you.
CCCC: <incredulity permanently tattooed to her face> Excuse me?
CP: You could have called before you came down. You could have come inside. We attempted to ring you but you mustn't have heard the message.
CCCC: I deserve compensation for wasting my time and gas.
CP: I didn't realise gas was such a sought-after commodity and Pharmacy Town was in the middle of it. Did the apocalypse happen while I was stuck in here and now we're in the middle of Max Max? Let's think about this for a moment because no one ever does the math. Your vehicle averages about 20 MPG. It's 4 miles to your house. Since you were coming here anyway, let's start the math from now. That's 4 miles home, 4 miles back. Add in 15 minutes of idling and that's less than 0.1 gallon each time. Right now we are at 8 miles and 0.2 gal used. At 8/20th of a gallon you are using 0.4 gallons driving. Add the idling 0.2 to this and you used a total of 0.6 gallons. With the cost of gas right now at $2.00 per gallon, your wasted fuel costs amount to $1.20. Even when gas was $4.00, you'd only be out $2.40.
CCCC: Well I deserve something.
CP: You got it. A math lesson and a history lesson.
CCCC: What history lesson?
CP: Next time you'll call ahead ... and listen to your voicemail.

Monday, February 27, 2017

The Debate

1. "Take one tablet by mouth every day."
2. "Take one tablet by mouth once a day."

Both directions say the same thing...or do they? According to some pharmacists, they are not entirely the same in their instructiveness. Let us examine a little closer.
CP's Partner and I conducted a very scientific poll. We asked our Phamilies, Phriends, Kids of Phriends, Random Strangers, and our Bartender to explain to us how they would take medication if they were given Option 1 or Option 2 on their bottles.

Conversation #1:
CP: How many tablets would you take if I told you to "take 1 tablet every day"?
People We Polled: <incredulous looks on faces> One.
CPP: And on how many days would you take one?
PWP: <still looking dumbfounded> Every day.

Conversation #2:
CP: How many tablets would you take if I told you to "take 1 tablet once a day"?
PWP: Seriously?
CP: Yes.
PWP: One.
CPP: Okay. Now the tricky question: On how many days would you take one?
PWP: Every day.
CPP: But it doesn't say "every day". It says "once A day". Couldn't this be interpreted to mean you get to select "A" day on which to take it?
PWP: You're arguing semantics with me.
CPP: Precisely!

Summary:
PWP: Why are you asking me this, again?
CP: We were having a debate. At work, we noticed a number of prescriptions, prescriptions we personally typed, getting sent back for correction.
CPP: We wondered why until we noticed that the same pharmacists were sending them back for the same reason...
CP: ...The two directions listed above. I believe that both are a fine option. Personally, I prefer Option #1.
CPP: Personally, I don't care, but Option #1 works fine for me. I just wanted to try to learn why some pharmacists were stuck on Option #2 being the ONLY correct option. Hence, my reply in Conversation #2.
CP: Unless they are insisting that the medication be taken at "the same time once a day"?
CPP: Okay, but they are still taking only one tablet every day. If they were really that hung up on "at the same time" then could they not amend Option #1 to "at the same time every day"?
CP: True.
PWP: You are both really weird.
CP: But we yearn to know. To understand our fellow colleagues. To boldly go where no one has gone before. To...
CPP: They get it.

*For the record, we know "ONCE' means "eleven" in Spanish and that can be confusing but that is not the gist of this debate.
*Second, there is a HUGE difference between "Take 2 tablets once a day" and "Take 2 tablets every day". While the patient will take a total of 2 tablets either way, the timing is different. It's either 2 at the same time, or 2 throughout the day which could be taken 19 minutes or 16 hours and 11 minutes apart.
*By adding a simple "prn" or "as needed" to either of these changes them as well. Again, not the point.


What say you?


Tuesday, February 21, 2017

Demo Time

The next time someone asks why it takes so long to fill your prescription, I'm going to send over one of my highly trained, cynical representatives to perform a demonstration.
We will have a demo cart set up with the following items: empty vials, safety lids, non-safety lids, a blank label, a completed "test" label, random tabs/caps we found under the counter (or M&M's), a counting tray, a spatula, and the most illegible, poorly written or typed prescription we have seen in our pharmacy. 
Then, in our tone most snarky, we shall commence the lesson.

See this blank label? Uh-huh. This is the before. Yep. See this completed one, the one with all the writing on it? Yep. We put that on there. But how does it get there? First you have to read the prescription. See this one? I can't give you XXXXXXXXXXX the way that it is written. It would either kill you, or it doesn't exist. See, your prescriber is just making it up as he goes along. Must have been the 5pm special, scribbling as he and his colleagues exeunt. Now we have to call the prescriber...

Fast forward to receiving a new, clean prescription. This could take seconds to weeks, depending on your office. Now we type it all in the computer. What we type in here (motions to computer) comes out there (waves hand over completed label). This is how we know what, and what quantity, to count. Now we have a big bottle of medication. Somehow, we have to make sure it is the right one. Uh-huh. Yeah. We can't just grab random medication off the shelf. That would be bad, m'kay? So we pull it. Then we scan it. THEN we count it. Let me demonstrate it for you.

<exhibits flawless, machine-like skills while wielding a CP 5000 model spatula and effortlessly sliding the chosen little doses across the smooth surface of the tray>

Then we have to select the appropriate size vessel for your medication. Easy with tablets as there is a graduated marking system on the side here <waves hand over the tray demonstrably>, but less easy with capsules. It takes experience and know-how to gauge the size. We then bust a cap on it. THEN, and this is every patients' favourite part, we professionally apply a label to the bottle, delicately rolling it so as not to impart creases or wrinkles (okay, we slap that bitch on there, but it's lovingly applied to appear straight and elegant). THEN...

...we hand it off to the pharmacist. Her job is to verify that what I put in there is what is supposed to be in there. I performed this demonstration for you in an aseptic, controlled environment. Normally, I would perform this task under duress; I would be answering phones, taking your drop off, fielding questions about the location of cotton balls, the bathrooms, and the sale item of the week and slinging pills like a short-order cook slinging hash. The pharmacist, once she is satisfied I didn't mislabel or misfill your bottle, will bag your order so you can go wait in line to retrieve it.
[Note: I skipped the part about the drug interactions, profile check, etc because that is the pharmacist's advance class (#WhyYouPrescriptionTakesSoLong II) which is available only on weekends and evenings for a nominal fee.]
Assuming no one in front of you decides to present a new insurance or discount card, it is quite likely you can proceed through checkout in a matter of minutes.

Hello? Sir? Wake up. Your prescription is ready. Sir?